Editor’s Note: A Commentary on this article appears on page 271.
The practice of medicine takes place within a dialogical relationship between the physician and the patient. Accordingly, most modern medical schools are now teaching relational and communicational skills to their students, often using actors to simulate medical encounters. Although the use of these simulation patients* is effective and has many advantages, simulation encounters differ from real medical practice in that they fundamentally alter the power dynamic in the relationship. Since simulation patients have recently been incorporated into national boards for evaluation purposes, it is now all the more important to reflect upon the nature and ramifications of such practice. Similar to Hodges,1 we wish to complement psychometric evaluations of simulation encounters, which have dominated the literature, with insights drawn from theoretical sociology and humanistic medical ethics. It seems to us that medical students must also learn how to appropriately manage the power that traverses the medical encounter and to create deeper human relations with real patients. Therefore, as a complement to teaching communication skills with simulation patients, we recommend the augmentation of fundamental humanistic learning and a reinvigoration of experiential bedside learning.
Teaching Doctor–Patient Communication With Simulation Patients
Effective physician–patient communication has been shown to improve health outcomes,2 patient compliance,3 and patient satisfaction.4 Consequently, many medical schools devote time and resources to teaching communication skills and the doctor–patient relationship.5 Commonly, teaching communication skills relies centrally upon the use of “simulation patients”—actors who play the prepared role of a particular patient in practice consultations with medical students.6–14 After these simulation encounters, the teacher, the simulation patient, and the other students can provide feedback to the student physician about how he or she related and communicated with the simulation patient, and the encounter can even be practiced again.
The use of simulation patients in teaching communicational and interpersonal skills has several advantages compared to other approaches, precisely because it is a simulation. One, the use of simulation patients creates a low-risk situation, wherein inexperienced students can practice the basics of good communication and gain personal confidence in preparation for later clinical work. Two, it allows educators to systematically design the training around a range of explicitly chosen situations, factors, and topics. Three, since the health of simulation patients is not really at stake (and the biomedical information can also be minimized), their use enables students and educators to focus more purely on the dimension of communication and relationship, without concern about medical treatment or the acceptability to the patient of the pedagogic feedback.
Empirical studies have provided encouraging evidence that the communication skills of medical students can be significantly improved through teaching programs making use of simulation patients.15–19 To our awareness, though, there are three shortcomings of this evidence base.19,20 First, almost all the evidence in the literature is limited to students’ immediate postintervention improvements, without long-term follow-up, even though there is some evidence that acquired communication skills can be lost.21 Research on the ability of fourth-year medical school objective structured clinical examinations (OSCEs) to predict first-year residents’ performance as assessed by residency directors have found “only modest”22 or no correlations.23 Second, the outcome variable is usually a rating of the students’ communicational abilities with further simulation patients; the evidence is not usually a rating of the students’ communication skills with real patients. Though sparse and mixed,24 the evidence thus far suggests that communication measures differ with simulation versus real patients.19,25–27 Third, the outcome evaluated, even when with real patients, is still usually an observer rating of the communication skills of the physician, rather than an objective measurement of the actual health and social outcomes of the patient. However, only patient outcomes truly show that communication has substantially improved in a meaningful way, not just in appearance to observers. The scientific community of medical education has already recognized the need for these kinds of staggeringly arduous studies.28–30 Meanwhile, we would like to suggest, from the vantage of medical ethics and postmodern theory, why and how teaching communication skills with simulation patients would probably be improved and enriched if it were complemented by humanistic learning with real patients.
The Power Relationship of the Doctor to the Patient
The doctor–patient relationship can be considered essentially a relationship of power or power/knowledge, in the sense described by the French theorist Michel Foucault.31–33 To analyze this relationship, let us start by considering something as basic to the practice of medicine as the physical examination. Routinely, the physician measures the height and weight of the patient’s body. These measurements are compared with statistical norms. In the process of the exam, the physician acquires knowledge about the patient’s body and simultaneously creates a relational dynamic between herself or himself and the patient, whereby the physician is measuring and evaluating the patient, and the patient is—for his or her own sake—submitting to this corporal objectification and medicalization. The bodily contact of the physical examination, though done for the health benefit of the patient, also creates a social power dynamic between the physician and patient.
The doctor–patient dialogue is likewise completely infused with power/knowledge relations. The doctor–patient dialogue is highly asymmetrical,34 with the doctor posing questions about the patient—his or her intimate bodily sensations, health practices, social milieu—the scientific meaning of which only the physician really understands. If the patient asks questions of the physician, it is only her or his expert knowledge, advice, or recommendations, not personal life or self, that are examined. Again, all of this sets up a dynamic of social power between the physician and patient. Further, since the physician’s questions and discourse are all guided by the gridwork of medical knowledge, the patient is led to reinterpret his or her experiences and life within a medical framework of understanding, and to guide his or her future behavior (e.g., drinking less alcohol, exercising more, taking a daily blood pressure medication or iron supplement) according to the vision of the medical community. The physician–patient dialogue is thoroughly infused with power, because it effects these changes in the thinking, behavior, and social persona of the patient.
It should be understood that when we speak of power relations in the doctor–patient encounter, this is not meant pejoratively as denoting something that is malevolent. As Brody has noted,35 these power relations are what make the encounter productive for attempting to improve the health of the patient, as well as achieving various other unacknowledged social ends. In the doctor–patient encounter, one outcome from this corporal examination is to calm and reassure the patient on a visceral level. Moreover, through the doctor–patient dialogue, the patient’s experience of malaise and uncertainty is inserted into the interpretive framework of the physician’s medical knowledge. The physician realizes these power effects upon the deep being of the dis-eased patient, through discourse and somatic interactions, because and only because the person of the patient is truly suffering from poorly understood painful experiences and the physician is invested by society with all available competence to improve the patient’s condition.
The Altered Power Dynamics in Simulation Encounters and Examinations
In simulation encounters, by contrast, this power relation between the physician (a medical student) and the patient (an actor) is fundamentally altered. The simulation patient is not really sick; and, moreover, knows already which illness and other issues he or she “has.” The simulation patient does not come to the encounter in an inner state of worry and dependence upon the physician, and she or he has the leeway to deliberately steer the course of the improvisation. On the other side, the medical student is not yet a physician and is not yet recognized by society as competent and responsible for taking care of patients. He or she may feel unsure what to ask the patient and uncertain what the replies mean. The student may feel nervous and stressed, and she or he may not feel “like a doctor.”36
The power relation is inverted, because knowledge and judgment rest with the simulation patient rather than with the physician student. Moreover, the usual doctor–patient power dynamic simply vanishes, because the entire interaction is merely a simulation with no real lasting influence on the bodies and minds of the two persons. The clearest indication that this power dynamic evaporates in the simulation encounter is the following hypothetical scenario. If a real physician brusquely orders a patient to disrobe, most patients will blushingly do so. The patient will experience himself or herself as an object of medical investigation, and may have a lingering sense of being disrespected. In the simulation encounter, though, if the student gives the authoritarian command, “Take off your clothes,” the simulation patient will not blush, would probably balk a moment, may even state a refusal or comply reluctantly, and will likely be grudgingly thinking that he or she will “get” this student in the feedback round—after which the event has no further personal significance except as an incident in an educational exercise. Since the fundamental defining feature of the physician–patient relation—the power dynamic as described above—is missing in the simulation encounter, the simulation encounter becomes a flat, two-dimensional imitation, no longer motivated by genuine anxiety and real healing.
Communication skills are now examined with OSCEs—a series of stations where medical students interact with simulation patients (or perform other tasks)9,37–43 —even for national boards.44–47 Hodges writes, “All examinations are acts of power … yet the potential distorting effects of the enactment of power are little discussed in validity research”48p.251; we would like discuss these distorting effects. In any simulation encounter, the dialogic power of the doctor–patient relationship is inverted and made substanceless. In the OSCE situation, it is also overwritten by another, new, entirely different mode of power relations: the silent, visual, surveillance power of the teacher/student relationship.31,32,49 Unlike a real physician–patient encounter, the OSCE adds faculty evaluators, who observe, judge, record, and analyze the student’s performance according to multiple factors. It is impossible to exclude these third parties from any serious anthropological analysis of the OSCE situation. The student knows that his or her every move and word is being watched, evaluated, notated, and quantified, and he or she knows that the further course of his or her immediate life as a medical student is dependent upon those evaluations by the silent faculty observer. The instructor’s evaluation is no mere simulation, and this evaluative observation changes how the observed student thinks and acts.1,9,25,48,50 Whatever the student physician says to the simulation patient is in fact said to impress the faculty observer, not for the well-being of the actor (who is not sick anyway). The responsibility to heal the patient is simply nonexistent in the OSCE, cannot be simulated, and does not generate the interactional dynamics. We suggest therefore that although the OSCE probably does serve as a reliable indicator of many partial communicative skills, it is not truly valid as an assessment of the ability of the overall doctor–patient relationship to affect health outcomes, precisely because the power dynamics of the OSCE situation differ so substantially from those of real medical encounters.
Despite our argument to the contrary, in context, simulation encounters seem quite realistic to the students who participate in them,6,7,12,24 as well as to the educators that use them. However, simply because simulations seem pretty realistic to everyone (ourselves included), this does not necessary mean that they actually are realistic. Instead, this verisimilitude could equally well prove that we are not able to clearly perceive what has been lost: the power dynamics, which determine what the doctor–patient relationship really is.
Since power has been drained out of the “physician”–“patient” communication in these encounters, the exchanges become more so a simulated imitation of a real physician–patient encounter. A medical student may, through practice in simulations encounters, be able to master all the skills and tricks of surface communication and be able to use them very effectively in an OSCE and in later practice. But does he or she ever learn to really relate to patients? Does he or she ever learn to master the discursive and ontological power that makes the physician–patient relationship an invigorated, productive, lived reality, rather than a set of acting techniques and formal procedures? There is no way to discern this in an OSCE, especially with a mere quick, schematic checklist. Therefore, the OSCE would not meet Harden and Gleeson’s criteria of validity38, p.41, if extended to assess the doctor–patient relationship and communication (formerly referred to as “attitude to patient”).
At many well-funded medical schools, most students will have their encounters with simulation patients filmed so that they can be reviewed by the class and instructors.6,8,51–53 Students thus learn to be good physicians from the outside. They learn to observe their own behavior and speech as a television viewer would. They receive feedback, from their fellow television viewers, on how to improve their acting performance. This may be useful in many ways, but it does not teach students how to be good doctors from inside the heart. The students are to a certain degree trained in acting to put on good performances for patients.
Of course, every professional has a certain role to play for his or her clients.54,55 Certain behaviors and a professional demeanor are expected of doctors, and doctors must in some sense “play” that “role.” The orientation of simulation training goes far beyond this though. It does not merely attempt to cultivate a certain professional demeanor, but it actively trains students to become simulacra. Students strive to imitate simulated model encounters that are presented on video for them: life imitates art. The student is encouraged to systematically simulate whatever it is that people perceive as an ideal physician. The student is not just informally imitating an admired role model, and later the physician is not just playing the appropriate professional role for a given social context, like any other person at work might. Instead, the student is encouraged to simulate an ideality that cannot be found whole anywhere in reality, and later the physician is creating a systematic projection of the good physician, behind which the original real person has entirely vanished.56 The authenticity that enables a robust physician–patient relationship is not likely to be taught by such simulation encounters. And since simulation training may soon in the name of safety be expanded to every aspect of health care,57,58 educators and bioethicists should consider its utility as an evaluative or training tool.
Teaching Students Not to Act Like Good Doctors but to Be Good Doctors
If we want medical students to be able to be good doctors rather than merely to act like good doctors, then we need to also teach them to actually create authentic relationships with their patients, from inside themselves (from their hearts, so to speak). The question thus arises, “Well, how do you do that?”
Developing good relationships with patients requires knowing them not just as moving biochemical anatomy models but as interesting, quirky, idiosyncratic persons, as human beings living in the human condition. The only way it is possible to know another human being as a human being, though, is first to really and profoundly know oneself as a human being. But knowing oneself as a human being is not a process that just happens automatically with age; it must be somehow cultivated or acquired.
Like most aspects of medical education, teaching the doctor–patient relationship necessitates both a clinical and a fundamental dimension, which must be thoroughly integrated with one another. Clinically, the best way to cultivate these sensibilities in young trainees is to expose them to the diversity of tragedy and joy encountered in real hospital settings.59 These interpersonal sensibilities are unlikely to be truly cultivated in simulation encounters, where only a grade is at stake, but this will probably happen in real encounters, where a physician’s choices result in real tears of joy and bereavement. Furthermore, the variety of idiosyncrasies of patients’ stories is what gives them a depth that usually is lost in standardized scripts, so students should learn at the bedside60–62 to hear the full stories of real patients.63 This can be accomplished even from the first year of medical school. Goroll and colleagues, for example, have shown that first-year medical students can learn interviewing skills by conducting supervised initial interviews with primary care outpatients.64 Bloch reports on a fascinating and highly promising approach to teaching first-year medical students the doctor–patient relationship and the art of accompanying dying patients by pairing these students with selected terminal cancer patients in regular supportive sessions that continue until the patient dies.65 These kinds of courses employ experiential learning, pioneered in modern times by Dewey, where the student learns by doing something with real significance.66
As to the fundamental dimension, students must be given the opportunity to cultivate themselves as mature human beings before they can develop their capacity to deeply understand and truly care for strangers. Medical students do not go to school only to learn a professional trade; they also attend school to grow as persons. Knowing oneself as a human being was a large component of classical and Renaissance humanist learning, before the rise of positivist science and technology. Even today, though, humanist learning persists in literature,67,68 anthropology,69,70 and the humanities,71,72 and it should be taught in medical schools,73–75 in order to truly develop students’ professional and interpersonal skills. Through such humanist learning, students learn more about themselves as human beings.
Studying the human experience in literature and art enables students to better understand their own experiences and lives, and ultimately to be better able to relate to other persons, including their patients. Without this cultivation of self-knowledge, the student cannot be fully effective in interacting with patients,76 because the student does not yet have the inner personal capacity to handle all the joy and bereavement and responsibility and stress in a hospital, may therefore feel overwhelmed, and would then shut off to the patient.73 A deeper, liberal-arts style understanding of culture,77,78 language,79,80 and the human condition81,82 endows the student with the depth of personal resources to truly care for so many distraught patients. The combination of deeper humanistic learning and mentored bedside encounters with genuinely ailing patients will foster the ability to create authentic, robust doctor–patient relationships. A physician who relates to his or her patients on a deeper level will learn, know, and care more about his or her patients. From the other side, a patient who feels related to in this way will have greater trust in the physician and will more likely be compliant with treatment. In short, although it may be difficult to objectively demonstrate, it is this genuine engagement that really powers the therapeutic relationship, even though we may not have the capacity to fully quantify all its effects.
Only when a physician has this humanist understanding of his or her own self (whether acquired through the university, in life more broadly, or both) can he or she perhaps come to understand who the other, the patient, is. It is this deeper kind of human understanding and relationship that enables the doctor–patient encounter to become truly productive, fulfilling, and therapeutic. As Osler noted in his 1919 address to the Classical Association at Oxford, “the men of your guild secrete materials which do for society at large what the thyroid gland does for the individual. The Humanities are the hormones.”83, p.26
The authors would like to thank anonymous peer reviewers for their feedback on this article.
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*In the medical educational literature, these actors are referred to as both “standardized patients” and “simulation patients.” We have opted for the latter term to emphasize the constructed nature of the encounter and the fact that the “patients” are not really patients.